Chronic Elbow Dislocation (Without Fracture): Open Reduction + Bell-Tawse + Tommy John Procedure

Preoperative Planning

• Plain radiographs (AP + lateral elbow): confirm chronic posterior dislocation, assess degree of ossification/heterotopic bone
• CT scan: evaluate bony architecture, fibrosis, and any incipient arthritis
• MRI: assess collateral ligament integrity, capsular contracture, and soft tissue envelope
• Neurovascular exam: document ulnar nerve function (commonly neuropathic in chronic cases)

• Supine with radiolucent arm table on affected side
• Shoulder should have adequate external rotation to access medial side; if stiff shoulder — lateral decubitus or arm-across-chest position
• C-arm fluoroscopy brought in from the head of the table for AP and lateral views
• Sterile tourniquet available (optional)

• Suture anchors (small and medium)
• Heavy non-absorbable suture (No. 2 Fibertape or equivalent)
• Bone tunnels / drill set
• External fixator set (static)
• Palmaris longus/gracilis/hamstring graft (for UCL reconstruction)
• Tendon stripper, graft preparation board
• Fluoroscopy

PART 1 — OPEN REDUCTION OF CHRONIC ELBOW DISLOCATION

Step 1 — Skin Incision

• Posterior midline incision, from mid-humeral shaft proximally to 5 cm distal to the olecranon tip
• Use subcutaneous border of ulna distally and midportion of humerus proximally as guides
• In cases with gross deformity, connect both ends of planned incision first to ensure proper orientation
• Raise full-thickness fasciocutaneous flaps: lateral flap elevated first, then medial flap if medial repair needed

Step 2 — Ulnar Nerve Identification and Protection

• In the medial flap elevation, identify and protect the ulnar nerve in the cubital tunnel
• Neurolysis if nerve is tethered/scarred
• Do NOT routinely transpose unless there is pre-existing neuropathy
• Keep the nerve visualized throughout the procedure

Step 3 — Lateral Side Release (Approach Lateral First)

• Open the Kocher interval between anconeus and extensor carpi ulnaris (ECU)
• Release the contracted lateral collateral ligament (LCL) and extensor muscle origin from the lateral epicondyle of the humerus — this is the primary restraint preventing reduction in chronic cases
• Release the lateral capsule — this may be significantly thickened and fibrosed
• Preserve as much tissue as possible for later repair/reconstruction

Step 4 — Medial Side Release (if needed)

• Elevate medial flap; protect ulnar nerve
• Release medial collateral ligament (MCL) and flexor-pronator origin from the medial epicondyle if still blocking reduction
• Elevate flexor-pronator mass off the ulna to aid exposure

Step 5 — Joint Débridement

• Resect the posterior capsule and anterior capsule entirely (thick fibrous membrane)
• Remove all fibrofatty scar tissue, fibrocartilaginous membrane, and organized hematoma from within the joint
• Elevate the triceps from the posterior distal humerus to allow the joint to open anteriorly
• Curette/remove any heterotopic ossification blocking reduction
• Thoroughly irrigate the joint — remove all loose bodies, degenerative debris, chondral fragments

Step 6 — Open Reduction of the Elbow

• Apply longitudinal traction on the forearm with the elbow flexed
• Use a bone lever/elevator to disengage the trochlea and olecranon
• The coronoid process is levered anteriorly under the trochlea
• Gentle manipulation — avoid forceful levering which may cause iatrogenic fracture
• Confirm reduction with fluoroscopy: concentric joint, trochlea seated in the trochlear notch of the olecranon
• Test for stability: gravity extension test in supination (LCL integrity), and pronation for posteromedial instability

PART 2 — BELL-TAWSE PROCEDURE (Annular Ligament Reconstruction)

The Bell-Tawse procedure uses a strip of triceps tendon to reconstruct the annular ligament around the radial head, restoring radiocapitellar joint stability. It was originally described for chronic radial head dislocation (Monteggia-type) and is adapted here for chronic ulnohumeral/radiocapitellar instability.

Step 1 — Graft Harvest (Triceps Tendon Strip)

• A strip of triceps tendon is harvested: approximately 10 cm long × 0.5 cm wide, taken from the posterior distal triceps
• The strip is left attached distally at the olecranon (pedicled flap) — this is the classical Bell-Tawse
• Alternatively, a free graft (palmaris longus, gracilis) can be used if pedicled strip is insufficient
• Prepare the graft on the back table: tubularize if needed, tag with traction sutures

Step 2 — Radial Head Exposure and Preparation

• Through the lateral Kocher approach already developed, expose the radial head
• Remove the remnant of the torn/absent annular ligament
• Clean the neck of the radius circumferentially — remove any fibrous tissue around the radial neck
• Confirm the radial head can now move freely in the radial notch of the ulna

Step 3 — Ulnar Tunnel Drilling

• With a 2.5–3.5 mm drill, create a tunnel through the proximal ulna at the level of the radial notch
• The tunnel passes from anterior to posterior through the ulna, just below the radial notch
• The graft will encircle the radial neck and pass through this tunnel

Step 4 — Graft Passage and Wrapping

• Pass the free end of the graft through the ulnar bone tunnel using a suture passer
• Wrap the graft around the radial neck in a loop — this recreates the annular ligament
• If using the modified technique with EndoButton (cortical fixation): pass graft through the tunnel and secure with EndoButton on the far ulnar cortex (PMC11923812)
• Bring the two ends together and suture them with No. 2 non-absorbable suture under appropriate tension
• The graft should allow smooth rotation of the radial head (supination/pronation) without constriction

Step 5 — Stability Check

• With the radiocapitellar joint reduced, confirm:
  • Radial head seated concentrically against capitellum on fluoroscopy
  • Free forearm rotation (supination/pronation) present
  • No subluxation of radial head with stress testing
• Repair the lateral capsule over the construct

PART 3 — TOMMY JOHN PROCEDURE (UCL / Medial Collateral Ligament Reconstruction)

The Tommy John (Jobe technique, modified docking technique) reconstructs the anterior band of the medial ulnar collateral ligament (MUCL) — the primary restraint to valgus stress at the elbow, using a tendon graft through bone tunnels in the medial epicondyle and sublime tubercle of the ulna.

Step 1 — Graft Harvest

• Palmaris longus is the most common donor (absent in 10–15% — check preoperatively)
• Alternatives: gracilis tendon, plantaris tendon, hamstring, or ipsilateral toe extensor
• Harvest palmaris longus via 1–2 small transverse incisions in the forearm, harvesting 15–18 cm of graft
• Prepare graft: tubularize with running locking suture (No. 1 Vicryl or FiberLoop) at both ends, leaving 2 cm tagged tails for docking

Step 2 — Medial Approach and Ulnar Nerve Identification

• The medial flap is already raised from the open reduction above
• Identify ulnar nerve in cubital tunnel; protect throughout
• Split the flexor-pronator mass in line with its fibers (between FCU and FDS) — modern technique avoids complete detachment
• Older Jobe technique: detach flexor-pronator origin off medial epicondyle (now largely abandoned due to morbidity)
• Expose the MCL and underlying capsule

Step 3 — MCL Exposure and Assessment

• Incise the MCL in line with its fibers: the Y-shaped incision between the anterior and posterior bands
• Inspect the joint through the capsulotomy: assess articular cartilage of medial trochlea and coronoid
• Excise the remnant torn/attenuated MCL (or preserve as augmentation bed)

Step 4 — Ulnar Bone Tunnel (Sublime Tubercle)

• Identify the sublime tubercle on the medial ulna — the footprint of the anterior band of MCL
• Using a 3.2 mm or 4.5 mm drill:
  • Drill the primary tunnel at the sublime tubercle — directed medially
  • Create two diverging exit tunnels on the subcutaneous border of the ulna (2 cm apart), creating a U-shaped bone bridge
  • Connect these with a curved curet (create the docking tunnel)

Step 5 — Humeral Bone Tunnels (Medial Epicondyle)

• Docking Technique (Altchek/Petrie — most commonly used):
  • Identify the isometric point of the MCL on the medial epicondyle (posterior-inferior aspect)
  • Drill one large tunnel (4.5 mm) into the epicondyle — main graft docking tunnel — depth 15 mm
  • Drill two small (2 mm) exit tunnels from the roof of this tunnel exiting on the proximal surface of the epicondyle for suture passage
• Jobe Figure-of-8 (original):
  • Drill two convergent tunnels in the medial epicondyle — anterior and posterior — connecting within the epicondyle

Step 6 — Graft Passage

• Docking technique: Pass the graft through the ulnar tunnel in a U-loop configuration; both free suture-tagged ends exit on the medial ulnar surface
• Lead one end of the graft into the humeral docking tunnel using a suture retriever
• Pull the graft until the midpoint is centered at the ulnar tunnel

Step 7 — Graft Tensioning and Fixation

• With elbow at 30° of flexion and valgus stress applied:
  • Tension the graft — pull both suture tails out through the small exit holes on the medial epicondyle
  • Tie the sutures together over the bone bridge with the elbow in 30° flexion (or per surgeon preference)
• Stability check: apply valgus stress at 30° — confirm tightness and absence of medial gap
• Fluoroscopy: confirm concentric joint reduction

Step 8 — Native MCL Augmentation

• If any native MCL tissue remains, suture it to the new graft to augment the repair
• This promotes incorporation and biological healing

Step 9 — Flexor-Pronator Repair

• Close the split flexor-pronator mass with interrupted absorbable sutures (Vicryl No. 1)
• If the origin was formally detached (Jobe original), reattach with suture anchors to medial epicondyle

Step 10 — Ulnar Nerve Management

• If ulnar nerve was symptomatic preoperatively or was disturbed during exposure:
  • Perform anterior subcutaneous transposition or submuscular transposition
• If nerve was merely retracted, return to normal anatomical position

PART 4 — WOUND CLOSURE AND STABILIZATION

Step 1 — Lateral Side Closure (LCL Repair)

• Repair LCL and extensor muscle origin back to lateral epicondyle using:
  • Transosseous bone tunnels or suture anchors at the center of the capitellum arc
  • Locking Krackow sutures in LCL, second suture in extensor fascia
  • Tied with forearm in pronation at 90° flexion
• Confirm: no posterolateral subluxation with supination-extension gravity test

Step 2 — Final Stability Assessment Under Fluoroscopy

• Move elbow through full arc of motion under image intensifier
• Confirm concentric reduction throughout range of motion
• If still unstable → consider static external fixator or internal joint stabilizer (Skeletal Dynamics IJS)
• Cross-pin/screw fixation is a last resort only

Step 3 — Wound Irrigation and Closure

• Irrigate the wound thoroughly with normal saline (pulse lavage)
• Close deep fascia with absorbable sutures
• Subcutaneous layer — 2-0 Vicryl
• Skin — suture closure preferred over staples (better wound edge security for early motion protocol)
• Sterile dressings

Step 4 — External Fixator (If Required)

• If soft tissue repair is tenuous:
  • Apply static external fixator with elbow at 90° flexion, concentrically reduced
  • 2 humeral pins (lateral) + 2 ulnar pins (lateral) — open pin placement to avoid radial nerve
  • Maintain for 4–6 weeks, then remove under anesthesia
  • Begin range-of-motion protocol after removal

PART 5 — POSTOPERATIVE CARE

Key Reference Textbooks

Summary of Combined Surgical Steps (Quick Reference)

1. Positioning (supine, arm table, C-arm)
2. Posterior midline incision, raise bilateral flaps
3. Identify and protect ulnar nerve
4. Lateral Kocher approach → LCL/extensor release
5. Medial approach → MCL/flexor-pronator release (if needed)
6. Joint débridement — capsulectomy, remove fibrous scar, irrigate
7. Open reduction under traction + leverage
8. Bell-Tawse: harvest triceps strip → tunnel through ulna → wrap radial neck → fix annular ligament
9. Tommy John: harvest palmaris → muscle-splitting medial approach → ulnar sublime tubercle tunnels → medial epicondyle docking tunnels → pass and tension graft → tie sutures
10. Augment with native MCL remnant
11. Ulnar nerve management
12. LCL repair with bone tunnels/anchors laterally
13. Fluoroscopy stability check
14. External fixator if needed
15. Layered wound closure
16. Splint at 90° flexion — begin rehabilitation protocol